Postpartum depression in mothers of infants under 12 months at Hai Duong Pediatric Hospital and its association on infant health

The PPD status of mothers having infants under 12 months and its association with the infants’ health status were examined by the hospital-based cross-sectional study.

Mothers with infants under 12 months of age attending outpatient visits and receiving inpatient treatment at Hai Duong Provincial Pediatric Hospital.

Hai Duong Pediatric Hospital was chosen as the focal point of this study due to its representation as a prototypical pediatric hospital of the Northern region with a stable patient flow of approximately 300 outpatients daily and more than 20,000 inpatients annually.

The research was conducted at Hai Duong Provincial Pediatric Hospital during the period from September 12th to 23rd, 2022.

Sample size:

The study to examine the prevalence of PPD, thus the sample size calculation follows the formula for determining a proportion:

In which, $Z^2{}_{\left(1-\frac{\alpha }{2}\right)}={1.96}^2$ denotes the statistical significance level (α=0.05), p represents the estimated PPD in mothers based on Fisher et al.’s study in Ha Nam (p=0.13) [14], d=0.05 represents the desired precision, and an additional 5% is added to account for potential dropouts. The calculated sample size is n=180, ensuring a robust statistical foundation for the investigation.

A convenience sampling method was employed. Any mothers who met the inclusion criteria in the study duration when seeking health services for their infants in the hospital and concurred to participate in the study were recruited until the sample size was obtained.

The study’s participants are selected from Hai Duong Pediatric Hospital, which may introduce selection bias. Mothers who visit the hospital more frequently might be overrepresented in the sample. To address this bias, the data collectors were trained to screen inclusion and exclusion criteria when recruiting the participants to avoid duplicate responses.

The study encompassed the following index variables:

Demographic factors includes age, occupation, household economic status, and educational level.

Infants’ health status pertains premature birth, birth weight, abnormalities at birth, health issues within the first 12 months of life, frequency of hospitalization, frequency of infant crying for more than 15 minutes per day, maternal concern frequency regarding child health.

Maternal PPD status was screened by utilizing the standardized Edinburgh Postnatal Depression Scale (EPDS) validated for Vietnam by Giang et al. [15], given its specificity for pregnant and postpartum women. The EPDS includes 10 questions, each consisting of 4 answer choices, scored on a scale from 0 to 3. Specifically, questions 1, 2, and 4: the scoring assigns points incrementally from 0 to 3; questions 3, 5–10 are scored conversely from 3 to 0. The total score ranges from 0 to 30 points. The cut-off threshold for PPD classification in this study was set at 12/13, a clinically diagnosed standard with high specificity [16,17]. The study participants with a total EPDS score of 13 or higher were categorized as having PPD status. The reliability of the EPDS scale was internally tested to ensure its appropriateness for measurement in the study population before conducting further analyses on the association between risk factors and PDD. The Cronbach’s Alpha value of 0.855 indicated a high level of reliability, ensuring the EPDS’ validity and reliability in screening PPD status within the target population.

The information about relevant factors within the 12-month postpartum period and indicators of PPD, as measured by the EPDS over the previous seven days, was obtained through structured and questionnaire-based interviews with mothers.

Before the data collection process began, the investigators, who were highly skilled, received training on how to use the research instrument.

EpiData 3.1 was used for data entry. The data was then extracted and cleaned up in IBM SPSS 26.0 (Armonk, NY, USA).

Descriptive statistical analysis was employed to delineate an overview of the study population, the infants’ health status, and maternal PPD status. Univariate analysis with Chi-square test was utilized to determine the association between PPD status and factors related to the infant’s health status with a significance level of p<0.05.

A comprehensive summary of the study participants’ demographic details is given in Table 1. The average age of the 180 individuals involved in the study is 27 years, women occupying the largest percentage of the population with 60.0%—fall within the 25–34 age range. Seventy-two percent of the female participants come from rural areas, accounting for over three quarters of the total. Most study participants have completed their higher education beyond high school. Workers and housewives constituted the largest occupational group, representing 37.9% and 20.3%, respectively. The majority of research samples (97.9%) are married and live with their partners. More than half of the women participating in the study reside with their mothers-in-law (53.3%), while the remaining women either living independently (35.6%) or living with their biological parents (11.1%). These demographic insights provide a foundation for understanding the sociodemographic composition of the study cohort, contributing to the contextualization and interpretation of research findings.

Based on the EPDS, each individual within the study cohort obtained her total EPDS score. The PPD status was categorized by the classification cut-off point, the threshold at 12/13 on the EPDS score. A notable 32.8% of individuals within the study cohort surpassed the classification cut-off point. This outcome underscores a significant prevalence of PPD within the examined population (Fig. 1).

Fig. 1. Prevalence of postpartum depression (PPD) based on Edinburgh Postnatal Depression Scale (EPDS) classification in the study cohort.

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The findings in Table 2 regarding the relationship between PDD in mothers and factors associated with the child’s health status. Specifically, the frequency of infants admitted for inpatient treatment two or more times in the first year of life is associated with PDD in mothers (p=0.038). The prevalence of maternal PPD is almost twice as high in the group of mothers with children admitted for inpatient treatment more than twice compared to those whose children have never been admitted for inpatient care, with respective prevalences of 48.5% and 25.0%. Moreover, the children that daily cry for longer than fifteen minutes per time are a substantial risk factor for PPD in mothers. The prevalence of PPD is four times larger in mothers whose children cry for longer than fifteen minutes at a time daily comared tothose whose children cry for shorter periods (62.3% versus 15.4%, respectively). Frequent maternal anxiety for the child’s health is another factor strongly associated with PPD. Mothers who are often in this psychological state have a far greater prevalence of PPD (57.4%) than mothers who show little to no care for their child’s health (22.7%).

These complex associations highlight the diverse range of factors that impact PPD status in women, offering important new perspectives on the screening and management initiatives of mental health issues in postpartum mothers.

With a cut-off point of 12/13 on the EPDS score, the PPD prevalence found in the study is 32.8%. According to a thorough systematic review on PPD rates in the Asian region conducted by Klainin and Arthur in 2009, this rate is within the range of 3.5% to 63.3% [18]. Nonetheless, the prevalence of PPD in the study is higher than the typical rates reported in Vietnamese studies, when compared to research conducted in Vietnam. Noticeably, it is higher than the rates reported in the research conducted by Do Van Tam et al in Binh Dinh (12.1%) and the research conducted by Luong Bach Lan and collaborators in Ho Chi Minh City (11.6%), even though all of these studies used the same classification threshold as the present study. The inconsistence in PPD rates in Vietnamese studies can be attributed to the diverse socioeconomic, cultural, and societal characteristics of the studied cohorts, along with variations in the timing of PPD assessments.

A equivalent result was found using the same 12/13 criterion in the study carried out by Fisher et al. in Ho Chi Minh City. This study found that 33.0% of women have PDD. The analogy between the two studies—that is, their focus on a research population made up primarily of mothers whose children are hospitalized for treatment or examination—may help to explain this observation. The act of bringing children to hospitals for check-ups or inpatient care is acknowledged as a stress-inducing factor, causing substantial anxiety for mothers and exacerbating pre-existing depressive symptoms. The findings of this study and Fisher’s research are similar, which emphasizes the possible influence of stressors connected to child health conditions on mothers’ mental health in comparable situations [19]. This alignment strengthens the robustness of the findings and contributes to the broader understanding of PPD within specific demographic groups.

Our investigation sheds light on the complex dynamics between PPD and infant health, underlining the imperative of early identification of PPD risk factors for comprehensive mental health interventions. Remarkably, the findings we found highlight a strong association between the number of hospital admissions in the first year of the infant and the development of PPD in mothers. This is consistent with other studies, such the one conducted in 2004 that found different depression rates in mothers of healthy children versus mothers of infants receiving inpatient care (p<0.001) [20]. These findings are further supported by a 2017 study conducted at Nam Dinh Pediatric Hospital in Vietnam, which explains that childrens who are hospitalized frequently increase the risk of PPD in mothers by 5.3 times [13]. The complex association between hospitalization of infants and PPD in mothers is explained by the increased maternal caregiving demand from the child, as well as the stress and anxiety resulting from the medical procedures and the inadequate living conditions in hospitals. These factors collectively contribute to the manifestation of PPD in mothers [20].

Our research also reveals a strong correlation between PPD in mothers and their infants’ continuous crying behavior. This is in line with worldwide research trends, as demonstrated by the 2013 study by Radesky et al., which found that women who had infants cry for longer than 20 minutes a day had a fourfold increased risk of PPD [21]. In the Vietnamese context, persistent and intense infant crying, also known as “khóc dạ đề,” has been associated with PPD in studies like the one conducted in 2023 at Central Obstetrics Hospital by Nguyen Quang Bac et al., which highlighted that mothers were 4.42 times more likely to experience PPD if their infants cried nonstop at night [22]. The persistent crying behavior that infants display is frequently linked to particular health problems in young children, like stomach discomfort or malnutrition. Determining the exact reason for an infant’s protracted crying is still difficult and elusive. When mothers struggle with uncertainty about their child’s health status, this exacerbate their stress and anxiety levels [23]. Moreover, the crying patterns of infants have a negative effect on postpartum women’s sleep quality, aggravating pre-existing stress and acting as a trigger for PPD [13].

The current investigation further underscores that mothers who consistently express heightened concern regarding their child’s health face an increased risk of PDD, with an odds ratio of 4.58 compared to mothers whose children are in good health and do not harbor excessive worry in this regard. This result is consistent with earlier research, including a 2013 study by Radesky that found women whose infants have health-related problems are twice as likely to experience anxiety and despair. In particular, mothers whose infants have digestive issues are more likely to experience PDD (OR=4.0; 95% CI: 2.0–8.1) [21]. Parallel to these results, a longitudinal study that followed 132 mother-child pairs in 2012 explains that problems related to a child’s restricted weight gain and persistent maternal anxiety and stress about the child’s weight and health are contributing factors that increase the risk of PPD [24]. Similar results on PPD have been frequently obtained in Vietnamese research. Mothers of children receiving medical treatment had a 4.2-fold higher risk of PPD than mothers of children in good health, according to a 2017 study conducted in Nam Dinh. This was mainly due to the ongoing worry for their child’s well-being [13]. For postpartum mothers, the already challenging and stressful task of caring for a infant becomes further exacerbated when the child’s health is compromised, leading to frequent illnesses and discomfort. This not only exacerbates the mothers’ mental well-being but also heightens anxiety and stress levels, impacting the physical condition of mothers who must stay awake at night attending to their sick child and experience irregular eating habits while caring for an unhealthy infant.

Valuable insights into PPD among mothers with children receiving healthcare services have been provided by this exploratory investigation. The study highlights the relationship between a mother’s PPD and her children’s health. This preliminary research lays foundation for future PPD screening and intervention programs is laid by this preliminary research, which aims to address the complex relationship between mothers’ mental health and their infants’ wellbeing.

The study’s cross-sectional design, which provides a snapshot of PPD status and infant health at a specific point in time, may not fully capture the dynamic nature of these conditions. The hospital-based methods potentially lead to the limitations in generalizability due to predominant representation of mothers with infants experiencing health issues requiring hospitalization, resulting in overemphasis on depression status.